25199 _ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '-ELECTRICAL PERMIT NO
APPLICATION/PERMITPLUMBING-MECHANICAL n C '1 A
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION L J 1 J
RUILDINQADDRESS: SANITARY NO. APPLICATIO-NNSSUBMjfTALLDDAT
I G�V / ✓„"�” UNIT# LOT# z
NERS NAME: IWIPf NE: 2S� CONTRACTOR'S NAME: LIC NO: N/C CONTROL#
76
RCHITECl/HbiGINEER LiCN . ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pCz I hereby affirm Oat am licensed under provisions of Cmprer9(commencing with JOB DESCRIPTION
t-00 Section]O p)of Division J of the Business and Pros
le ions Code,and my licenseis in PANELS �
FF full tamarind effect.
1< License License Class Lic.N UP TO 2W AMPS
,<d- Dale Conlrimuo 201-1000 AMPS
Z�NZ ARCHITECTS DECLARATION OVER IOOO AMPS .FT.FLOOR AREA $/SQ.ET.
O7_O 1 understand my plans shall be used as public words.FNS SIGNS ELECTRIC C-
'# Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT ISC.
XO W U 1 hereby affirm that 1 am exempt from the Cameroon's License Law for the
W as
3Om following mance.(Section 7031.5.Business and Professions Coda Any city or county TEMP.METERORFOLE INST.
f'IS y j which requires u permit m conswa,otter,improve,demolish,or repair my structure
W'u3 of prior to in issuance,also requires the applicant for such permit to file asigned statement POWER DEVICES UiHls:
py K OO that he is licensed pursuant to the Provisions of the Contrzcmis License Law(Chapter
o-aozz 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING LELECIRIC
XmLL VALUATION
ty y of Wet h7031.5 by atherefrom and the basin oibjevllegedexemptipn. avil platior of !!��
F-Za
not
than bye undredicantfsTapemtit subj«tithe applicant toacivil penalty of OUTLETS-SWITCHES-FlXTURES (
ES not morethanfivehepoT dollars H$500).
W se I,asownensftheprppcny.prmycmployces with wagesestheirsolecomprnsetion, NEW RESIDENTIAL ELELTR _SQ.FT. S'1'Ok1E5 TYPE CONS'I'RUCTIOP
W .the work,and the structure is not intended proffered forsWc(Sec.J066,Business
d Professions Cede:The Contractor's License Law does out apply to an owner of
oponywhobuiIdsofimprovesI ciam,and whodoessuchwork himadforthrough his
cmployces,pmvidedthmsucbimprnvemennart notimendedorodfcrcdforsele.If, OCCGROUP RES.UNITS
however,the building or improvement is sold within one year ofeempletion,the owner.
builder will have the banderol that he did nolbrildor improve far TOTAL:
proving prove purpox pf
le.).
❑ 1.as owner project
(Sec,704,t,
exclusively an anmmctlions C de:) he Contractors
License,
QTY. PLUMBING PERMIT FEE FLOOD ZONE, nPN
mswa the Woject(sec.9064.Business and Professions orimp The floamo,and
Licenseemsfirxn«apply dano risme mthd whosed prortrmpruvea Comgmd PERMIT ISSUANCE
Liecom aw.for such projects witsaconwaprta)licenced pursuanuothe Conuadors
License Law. ALTER-DRAIN&VIiNT-WATER(EA) FEE SUMMARY
❑ 1 um enanpt under Sec. ,0&P C for this¢awn BACK FLOW PROTECT.DEVICE OUTSIDE FBLS
SANITARY Y_N
Owner Data
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTp
SCHOOLTAX Y N
❑ Ih'CompefirmthvIl Insurance
caddied conunuosf(Sesure,or Lab C.)which
PER TRAP
R[CEIPTp
Workeri Cpmpensationlrtsunnce orneenified copy thenof(Sec.3gW,lsb C.)which FlXTURFS-
PARK FEE YN
covers all employee under this permit GAS-EA.SYSTEM-1 INCA OUTLETS Rp
Policy p BUILDING DIVISION FEES
Company
El Certified copy is hereby famished. GAS-EA.SYSTEM-OVER 4 HQD PLANCHECK FEE
copy
❑ Certified CERTI Tiled withOF EXE inspectionON RivM W GREASFnNDUSTRL WASTE INTERC[PTOR GRADING FEE
CERTIFICATE OF F,XEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section ncd not becompletd iftbe permit is forone hundred dollars DIM) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
or less)
I certify hot in We performance of the work or which this pesmitis issued,Ishell WATER HEATER W/VENT/ELECTR
not employ any person in any mantra so as to become subjmt to the Workms' PAID
Compensation laws pf Catifomia Data FNEWR�21DENTJALPLMB._SQPF.
NG
Dale Receiptp
Q Applicant
z 0 NOT ICE TO APPLICANT:If.after making this Certificate of Exemption,you shouldTOTALr VJ become subjmuo Ne Worker's Compensation provisions of the Labor Code,you mustforthwith comply with such provisions or this permit shall he dcemd revoked.IY �_ BUILDING FEE LA ❑ CONSTRUCTION LENDING AGENCY SEISMIC FEEz I hereby affirm Nat there is a c amination lending agency for the performndeced
ONe work for which this permit is issued(S«.309],Civ.C.) TOTAL: ELECTRIC FEE
Landers NameQULender.+AddrcaaMECHANICAL PERMIT FEE PLUMBING FEE
R-I I certify that I have read this application and state that the above information is
FC Correa. 11—on-11y with all city and county ordinance andante laws admingm PERMIT ISSUANCE MECHANICAL FEE
_ building mnshuaion,and hereby authorize reprcsenntives ofthisciry,to enter upon the
U z above-memioncd property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupcnino against
limilitiea,jud enn,cosnandesprne hieyinany az eale..a a said City AIR HANDLING UNIT(TO 10.tX10 CFM)
of the ' god
s Alk HANDLING UNIT(OVER IU,B(XI CFM)
Sre of ApplicarUCpmnaor re EXHAUST HOOD(W/DUCT)
r
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000BTU) Dan RcceiptN
Will the applicant Mu building deamro
sre of handle hazardat
ousmerial
as decnd by the Cupertino Municipal Cade,,Chapter 9.12,and Ne Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Coda Section 25532(ap
❑Vee 11 No VENTILATION FAN(SINGLE kf51D)
Will the applicant� fund building ont ccupauseequipment ordevices which emit
BOILER-COMP(311POR IWIX
, p BTU) ISSUANCE ATE Wll minms air comnma us defend rm by the Bay AAh
DimrQuality Management BOILER-COMP(OVER I W,OfXI B'TU) R�
❑Yex ❑No NEW RESIDENTIAL MECH, SQ.FT. r A '
ID
L
read the mountain materials requiremems under Chapter 6.95 of the H
ulO&Safcry Grdc,S«tions 25505,25533 and 25536. I undennnd that Il,^,g does not currently have a tenant,that it is my responsibility to notify the �/(Ji1V1 14 ����he requiremenn which must be met primto issuance ofa Crnificad of
/'�hornad aged Doe TOTAL: ISSUED BYCIIT \del•�U ��IV�J